OT Potential’s Comment Letter to CMS on the 2027 Physician Fee Schedule Proposed Rule

Here is OT Potential's full comment letter, as was submitted to CMS on Sept. 14th, 2026. In it we ask for several changes that would allow OT and PTs to practice at the top of their licence, and ensure access to our cost-effective services.

Please see the short comment template we developed to for OT and PT professionals to share this same message.

You also see our post, How OTs and PTs are Blocked from Serving Older Adults, to see the problems with our current billing options this letter is seeking to solve.

OT Potential's Full Comment Letter to CMS

September 14, 2026

Secretary Robert F. Kennedy Jr.,
Department of Health and Human Services

Dr. Mehmet Oz, Administrator,
Stephanie Carlton, Deputy Administrator and Chief Clinical AI Officer,
Centers for Medicare and Medicaid Services

John Brooks, Deputy Administrator and Director,
Center for Medicare

US Department of Health and Human Services
Attention: CMS-1848-P; Mail Stop C4-26-05
7500 Security Boulevard
Baltimore, MD 21244

RE: Comments on Medicare and Medicaid Programs; CY 2027 Payment Policies Under the Physician Fee Schedule and Other Changes to Part B Payment and Coverage Policies; Medicare Shared Savings Program Requirements; and Medicare Prescription Drug Inflation Rebate Program; 91 FR 43842 (July 16, 2026); Docket No. CMS-2026-2377

Dear Secretary Kennedy, Administrator Oz, Deputy Administrator Carlton, and Director Brooks:

OT Potential appreciates the opportunity to comment on the CY 2027 Physician Fee Schedule (PFS) proposed rule. We support CMS’s focus on prevention, longitudinal care, accurate resource measurement, and payment for cognitive and coordination work. We ask CMS to apply those principles to occupational therapy (OT) and physical therapy (PT) while preserving the value of existing skilled treatment and the contributions of occupational therapy assistants (OTAs) and physical therapist assistants (PTAs). [1]

OT Potential is a continuing education and professional development organization based in rural Nebraska. We were founded in 2011 and have been an AOTA-approved provider of continuing education since 2020. We reach more than 28,000 practitioners in outpatient, home-based, hospital, and community settings. We do not furnish or bill for patient care, and nothing we request in this letter accrues to us. Our recommendations come from what practitioners tell us they cannot do for Medicare beneficiaries whose safe daily functioning depends on the interaction of physical health, cognition, behavior, environment, and caregiver capacity.

We are an OT organization, and we write here for both professions. Medicare pays outpatient OT and PT under one framework. The same plan-of-care rules, payment thresholds, multiple procedure payment reduction, and assistant policies apply to both. Our recommendations address those shared structures while respecting each profession's distinct scope and code families. [13]-[15]

If CMS acts on these requests, therapists could support the primary care team and take on real longitudinal management of the beneficiaries we are often best qualified to manage as frontline clinicians. Those include beneficiaries with movement impairments, functional impairments, musculoskeletal pain, deconditioning, balance disorders, fall risk, and post-surgical or neurological decline. Managing them well at the point where they first present is how the program avoids the downstream medical spending these and other conditions produce when they aren’t managed early and optimally.

We request that CMS:

• Finalize the proposed practice expense methodology reforms while addressing conversion-factor instability and unresolved therapy practice-expense distortions.

• Use its own statutory and regulatory authority to review and differentiate the existing OT and PT evaluation tiers and to develop two encounter-based therapist management services.

• Preserve the work and values of existing therapeutic exercise and other treatment codes, including the assessment, clinical reasoning, skilled adaptation, and treatment decisions those codes already contain.

• Open a future notice-and-comment pathway for occupational therapists and physical therapists to furnish HBAI services within applicable state scope and Medicare requirements. In this rule, keep health-coaching personnel standards from imposing duplicative private credentials on licensed OTs and PTs or narrowing covered therapy services.

• Support targeted legislation recognizing occupational therapists and physical therapists as ACO professionals under section 1899(h)(1), pursue broader statutory practitioner recognition separately with appropriate conforming protections, and improve therapy participation and data access under current authority.

This letter follows the proposed rule’s organization. Each section describes the relevant proposal, provides our comment, and states a concrete recommendation.

Index of comments by rule section

II.B. Determination of Practice Expense RVUs and Payment Stability

What CMS proposed. CMS proposes to reduce reliance on outdated specialty-specific practice-expense-per-hour data, phase out the indirect practice cost index over a two-year transition, and replace the final scaling step with a practice-expense stabilization adjustment that would generally limit annual increases or decreases in a code's practice-expense RVUs to 5 percent. CMS seeks comment on how that adjustment should apply to new, revised, newly nationally priced, and revalued codes. CMS's specialty-impact table estimates a 3 percent increase in total allowed charges for occupational therapy and physical therapy from the proposed RVU changes. That table does not include the statutory conversion-factor updates. CMS calculates proposed CY 2027 conversion factors of $33.17 for qualifying APM participants (QPs) and $32.84 for non-QPs. QP status is clinician-specific, and the proposed rule does not establish it for either profession or say how many OTs or PTs will receive the QP factor. This letter therefore uses the $32.84 non-QP factor as the benchmark for typical therapy billing. It is 1.68 percent below CY 2026. The year-over-year difference mostly reflects expiration of the one-year 2.5 percent statutory increase for CY 2026, partly offset by the 0.25 percent statutory update for non-QP services and an estimated positive 0.53 percent budget-neutrality adjustment tied to proposed work-RVU changes. [1] [2] [7] [31]

Comment. We support the proposed practice-expense reforms. Therapy depends heavily on clinical labor, and relying less on specialty expense data from 2007 or earlier should make payment track the resources actually used to furnish care. CMS declined to use the AMA's newer Physician Practice Information Survey data for CY 2026 after finding problems with response rates, representativeness, sample size, comparability, and incomplete submissions. That record supports moving toward objective, auditable, routinely updated data instead of preserving an old specialty allocation through a scaling mechanism. [2] [3]

The two percentages answer different questions. The 3 percent specialty estimate shows how proposed RVU changes redistribute payment, and it excludes the conversion-factor updates. Put the two together and therapy lands near 1.3 percent for CY 2027. That is a direction, not a projection of what any practice will be paid. Code mix, geography, modifiers, and therapy thresholds all move the result. [7] [31]

The proposed $32.84 non-QP conversion factor is not a discretionary CMS cut. Medicare calculates PFS payment from geographically adjusted work, practice-expense, and malpractice RVUs multiplied by the conversion factor. The conversion factor carries the statutory annual update and the budget-neutrality adjustment required when aggregate changes in relative values would otherwise move PFS expenditures by more than $20 million.

Restoring that increase, or building a durable inflation-based update, is work for Congress. CMS and HHS should support it. Two vehicles are already before Congress in substance. MedPAC recommended in June 2025 that Congress replace the current-law PFS updates with an annual update based on a portion of the growth in the Medicare Economic Index, and the Provider Reimbursement Stability Act of 2026 would raise the budget-neutrality threshold, require periodic updates to direct practice expense costs, and limit year-to-year variance in the conversion factor.

The underlying problem is that the current-law update does not address what it costs to furnish care, so the gap between practice costs and payment widens in most years no matter how accurately CMS sets relative values. Accurate relative values and an adequate update are two different problems and need two different fixes. [2] [7] [32] [33]

The 19 therapy codes reviewed for CY 2025 show a separate, code-level concern. CMS found that some recommended reductions in clinical-labor time would duplicate efficiencies already recognized when the therapy multiple procedure payment reduction (MPPR) runs during claims processing, and referred the inputs for further review. That correction process governs the accuracy of direct practice-expense inputs. It does not authorize CMS to repeal the claims-level MPPR. Section 1834(k)(7) sets the reduction at 50 percent for covered therapy services subject to the policy, in place of the 25 percent established in the CY 2011 PFS rule. CMS therefore cannot exempt therapy from the remaining MPPR or reduce the statutory percentage to zero through this rule, and CMS did not propose to do so for CY 2027. What CMS can do is make sure code-level direct inputs do not separately embed the same assumed efficiencies. We recognize that repealing or modifying the claims-level reduction takes an act of Congress. [4] [5] [6]

The stabilization adjustment raises a distinct question. A 5 percent annual limit on practice-expense RVUs makes for a long transition when a service is materially undervalued, and therapy is a practice-expense heavy family for the reasons above. A code whose fully implemented practice-expense RVUs sit 40 percent above their current level needs roughly seven years to get there, and a code that needs a doubling takes roughly fourteen. Both take longer if CMS applies the limit to a code's baseline value instead of to the prior year's. Applied symmetrically, the adjustment slows correction of the very services CMS has determined to be undervalued, which cuts against the misvalued-code review CMS conducts under section 1848(c)(2)(K). [1] [7]

Recommendation.

• Finalize the phaseout of the indirect practice cost index and the revised indirect practice-expense allocation.

• Apply the stabilization adjustment so it does not delay an evidence-supported upward revaluation of a new, revised, or demonstrably misvalued service. CMS should either set a fixed duration for the adjustment, after which any remaining difference is implemented, or adopt a larger annual percentage. Under either approach, CMS should publish the list of codes that meet the cap threshold in each direction, together with the number of years each would need to reach its full practice-expense value under the finalized policy.

• Use the CY 2027 practice-expense reform as the broader methodology change, and separately open a future notice-and-comment review of the direct practice-expense inputs for the affected therapy family using empirical labor, equipment, and supply data. Identify which duplicative reductions discussed in the CY 2025 record were corrected and which remain, with particular attention to the equipment times CMS flagged for further review.

• Support congressional action to establish a stable, inflation-linked PFS update, including the approaches above, and to repeal or modify the therapy MPPR in section 1834(k)(7). Until Congress acts, apply the statutory reduction as written while making sure the underlying code values do not contain a second reduction for the same assumed efficiencies.

II.D.1. CMS Authority to Create and Revalue Services Without a RUC Recommendation

What CMS described. The proposed rule describes how CMS values new, revised, and potentially misvalued codes, including the advisory role of recommendations from the AMA/Specialty Society Relative Value Scale Update Committee (RUC). We address this first because a mistaken assumption that RUC action is legally required keeps therapy proposals from ever reaching CMS, and every coding and valuation request below depends on what the statute actually permits. [1]

Comment. Congress gave this job to the Secretary. Section 1848(c)(2)(B) requires CMS to review relative values periodically and adjust them as practice, coding, data, and services change. Section 1848(c)(2)(K) directs CMS to find and correct misvalued services. Clause (K)(iii) says CMS may use existing processes to obtain recommendations. May, not must. The same clause separately authorizes CMS to run surveys and other data collection, perform studies and analyses, and hire analytic contractors to identify and value services. The RUC appears nowhere in the statute. Its recommendation is not a prerequisite to anything.

In 2014, Congress added subsections (M) and (N) through the Protecting Access to Medicare Act. Subsection (M) lets CMS collect resource information from eligible professionals and any other source, including electronic health records, billing systems, and practice records, provides $2 million a year for that work, and exempts the collection from the Paperwork Reduction Act. Subsection (N) lets CMS set or adjust practice-expense relative values using cost, charge, or other provider and supplier data. Congress does not fund an agency to build independent valuation capacity and then expect it to wait on an outside committee. Section 1848(c)(2)(L) separately requires CMS to validate time, mental effort and professional judgment, technical skill, physical effort, and stress. [7] [8]

For the evaluation families, the criterion that fits best is section 1848(c)(2)(K)(ii)(XI): anomalies in relative values within a family of codes. The low-, moderate-, and high-complexity OT and PT evaluations carry distinct descriptors and distinct typical times, and the same work RVU. We are not asking CMS to use section 1848(c)(2)(K)(ii)(V), which addresses low-valued codes billed multiple times, because clause (K)(iii)(V) also names consolidation or bundling as a possible response, and that makes it a poor vehicle for an upward revaluation request. We ask CMS to use the within-family anomaly criterion for the evaluation tiers, together with the broader data and validation authorities in clauses (K)(iii), (L), and (M). [7]

CMS sets work, practice-expense, and malpractice RVUs and applies nonfacility practice-expense RVUs to outpatient therapy paid under the PFS, publishes RVU and direct practice-expense changes through notice-and-comment rulemaking, may set interim values when payment must begin before the evidence is complete, and establishes uniform national definitions of services, codes, and payment modifiers. Section 1848(c)(5) likewise gives the Secretary the uniform procedure coding system. [9] [10] [11]

CPT code creation, RUC valuation recommendations, and Medicare payment policy are three different functions. The CPT Editorial Panel creates and revises the AMA-owned CPT code set. The RUC recommends relative values after codes exist. CMS may accept, reject, or modify those recommendations when it values CPT services, and it may create Medicare-specific HCPCS Level II G-codes with its own descriptors and values through rulemaking. HIPAA did not change those roles. Its administrative-simplification regulations adopt CPT and HCPCS as standard code sets for electronic transactions, and they do not make approval by the CPT Editorial Panel or a RUC recommendation a prerequisite to Medicare coding or valuation. [12]

Coding and coverage remain separate questions. A new code does not expand the statutory therapy benefit, change state scope of practice, or displace the rules governing plans of care, certification, therapy thresholds, and the assistant payment differential. CMS must address each of those when it implements a new therapy service. [13] [14] [15]

Recent examples of CMS using alternative methods

The examples below come from PFS rulemaking over the last ten years. [16] [17] [18] [19]

These examples show that CMS can define a Medicare service, select a crosswalk or comparative adjustment, collect its own data, and publish proposed values without treating RUC approval as a prerequisite. CMS may consider reliable outside submissions. No private advisory body should hold a required or gatekeeping role in the Secretary's coding and valuation process.

Recommendation. Confirm in the final rule that CMS needs neither a RUC recommendation nor RUC/HCPAC participation before it may correct a misvalued service or establish a Medicare-specific service. Establish the CMS-led therapy workstream below. Revalue the existing evaluation families under the misvalued-code authority in sections 1848(c)(2)(K)-(N). Develop Medicare-specific TM-M and TM-H codes under sections 1848(c)(5) and 1848(c)(2)(B), together with 42 CFR 414.24 and 414.40. Build the record through claims analysis, independent contractor studies, representative OT and PT data, direct practice-expense inputs, and beneficiary and assistant impact analyses, and keep the descriptors, resource analysis, proposed values, and final decision with CMS. [7] [9]-[11]

II.D.3.c(50) and (51). Behavioral Health Valuation and HBAI

What CMS proposed. CMS proposes to complete the transition increasing payment for timed behavioral health services, extend a comparable adjustment to smoking-cessation and screening/brief-intervention services, and revise values for multiple psychiatric collaborative care and advanced primary care management behavioral health integration services. [1]

Comment on valuation. We support valuing these services accurately. The proposal matters here because it shows two methods CMS has available: a comparative upward adjustment for a group of timed services, and code-specific valuation changes based on CMS's own assessment of relative resources. The two discussions cover eleven codes, six of them collaborative-care or behavioral-health-integration codes and five of them smoking-cessation or screening/brief-intervention codes. Any table in the final rule should separate the groups and name the method used for each. [1]

Recommendation on valuation. Finalize the proposed values for the collaborative care, behavioral health integration, smoking cessation, and screening and brief intervention codes. In the final rule, state which valuation method CMS used for each group and what evidence supported it. That record matters beyond behavioral health. It is the clearest recent demonstration that CMS can move work values when it concludes the evidence and the policy priority support doing so, and it is the model for the therapy workstream we request under II.D.4 and II.H. [1] [7]

Request for a future HBAI eligibility proposal

We support recognizing CPT codes 96156, 96158, 96159, 96164, 96165, 96167, and 96168 as "sometimes therapy" when a Medicare-enrolled occupational therapist or physical therapist furnishes them, within applicable state scope, as a medically necessary component of covered therapy. CMS did not propose HBAI practitioner eligibility in this rule, so we do not ask the agency to finalize an eligibility change without notice. We ask CMS to acknowledge the request in the CY 2027 final rule, name the coverage and operational questions it will evaluate, and announce a notice-and-comment proposal for the next feasible PFS cycle.

In CY 2024, CMS expanded HBAI eligibility for certain behavioral health professionals and declined the occupational-therapist request because the codes were not designated as therapy services. CMS should reconsider that for both OTs and PTs. [18]

Both professions have a sound practice basis for inclusion. Recognizing them would not enlarge state scope of practice. Occupational therapists and physical therapists would remain accountable under their licenses, state law, and professional standards for furnishing only what falls within their scope and competence. CMS should not create an additional HBAI credential, private certification, or profession-specific competency attestation that it does not require of other eligible practitioners. Occupational therapy's recognized domain covers health management, habits, routines, rest and sleep, social participation, and the personal and environmental factors that affect performance. OT-delivered health-management interventions have produced clinically relevant outcomes in trials such as REAL Diabetes. [20] [21]

Physical therapist practice covers management of movement and functional impairments, prevention, health promotion, and management of disease and disability. Psychologically informed physical therapy combines rehabilitation with graded activity or exposure for pain-related fear, education, goal setting, pacing, relaxation, and cognitive or acceptance-based strategies. When those services target psychological or behavioral factors affecting a diagnosed physical health condition, meet the HBAI descriptor, and fall within state scope, PTs have the same clinically coherent basis for reporting HBAI that OTs do. [22]

HBAI is not psychotherapy. Eligibility should turn on the service furnished, the diagnosed physical health condition, how behavioral factors relate to that condition, applicable state scope, medical necessity, and every element of the code. It should not turn on an extra credential imposed only on OTs or PTs. Recognizing the professions would not authorize anyone to diagnose or treat a mental disorder outside applicable law, and therapists would keep their ordinary duty to practice within scope and competence.

CMS should build these safeguards into a future proposal:

• Require a diagnosed physical health condition and documentation of the psychological, behavioral, emotional, cognitive, or social factor affecting its management or functional consequences.

• Require compliance with applicable state scope-of-practice law and ordinary professional standards. Do not impose a separate credential, certification, or competency attestation unique to OTs or PTs.

• Designate the codes as "sometimes therapy" only when furnished under an appropriate OT or PT plan of care, with GO or GP reporting and applicable certification and threshold rules. [14] [15] [23]

• Prohibit duplicate payment with an evaluation, treatment, cognitive intervention, caregiver training, psychotherapy, health coaching, or therapist management service for the same work or time.

• Publish examples that separate HBAI from routine education, motivation, adherence discussion, treatment adaptation, and psychotherapy.

• Address how assistant-furnished components may support a therapy plan under existing supervision and payment rules, without implying that an OTA or PTA independently bills or personally performs work the HBAI code or future CMS policy reserves to the therapist.

Recommendation. In the CY 2027 final rule, acknowledge the OT and PT HBAI request and announce a work plan for a future proposal covering profession eligibility, state scope, therapy designation, modifiers, plan-of-care rules, overlap edits, documentation, outcomes, and assistant participation. Treat licensure and existing professional obligations as the qualification framework instead of creating an additional HBAI credential.

II.D.3.c(56). Health Coaching Services (CPT Codes 0591T, 0592T, and 0593T)

What CMS proposed. CMS proposes national payment for health and well-being coaching services described by CPT codes 0591T, 0592T, and 0593T, and identifies education, training, examination, and supervision requirements for the personnel who furnish them. The proposed framework includes both direct- and general-supervision elements, which CMS should reconcile clearly in the final rule. [1]

Comment. Accredited OT and PT professional education and licensure already cover behavior change, health routines, physical activity, self-management, and functional goal attainment. CMS should recognize those overlapping competencies instead of requiring a duplicative private coaching credential or profession-specific proof of what education and licensure already establish. Recognizing OT and PT licensure for personnel-qualification purposes would not expand the therapy benefit, override state scope, or allow billing that is not otherwise authorized. [20] [22]

Recommendation. Finalize national payment for health and well-being coaching services. Establishing a payable longitudinal behavior-change service is the right step, and we support it. Modify the personnel standards before finalizing them. Treat graduation from an accredited OT or PT professional program and active licensure as satisfying the overlapping education, examination, and professional-accountability elements of the personnel standards, and do not require a duplicative private coaching credential. If CMS keeps uniform coaching-specific training for all qualifying personnel, recognize equivalent curricular and continuing-education content without a profession-specific examination or attestation. Reconcile the proposed direct- and general-supervision provisions. Nothing in the final policy should narrow OTA or PTA roles in covered therapy, treat separately payable therapy services as subsumed within coaching, authorize independent assistant billing, or alter the statutory assistant payment differential. [13] [14] [20] [22]

II.D.3.c(62). Caregiver Training Services

What CMS proposed. CMS seeks comment on whether the resource costs described by HCPCS codes G0541, G0542, and G0543 are best reflected in those codes or already captured in the valuation of other services, including evaluation and management visits. [1]

Comment. We support keeping caregiver training as distinct services. Effective caregiver training often determines whether a beneficiary can use a mobility, self-care, cognitive, safety, or behavioral plan outside the treatment setting. These services should stay available when medically necessary, and a new therapist management service should not absorb them.

They are also not captured elsewhere for the practitioners who furnish much of this training. Occupational therapists and physical therapists cannot bill office or outpatient evaluation and management visits. Treating these resources as already reflected in E/M valuation does not relocate the payment for a therapist-furnished service. It removes it.

The work differs from an E/M visit in any event. Developing an individualized training plan, assessing caregiver readiness and competence, adapting instruction to the beneficiary's condition and environment, and evaluating caregiver performance are planned instructional activities with defined objectives, not an incidental part of a follow-up visit.

A second obstacle is operational. For services furnished on or after January 1, 2025, CMS applied a claims edit it describes as Disposition 11, which requires that the practitioner furnish the full time stated in the descriptor before reporting an initial or additional unit. The midpoint convention that governs other face-to-face timed therapy services does not apply. A practitioner who furnishes 27 minutes of medically necessary caregiver training, meets the caregiver's needs, and appropriately ends the session cannot report the service at all. That pressures clinicians either to stretch a session past the point of clinical usefulness or to skip it. CMS published the edit through sub-regulatory guidance more than a year after the codes took effect. Early experience matches the concern: an April 2026 analysis of adoption found utilization limited and named clear guidance and reduced barriers among the conditions for broader uptake. [34] [35]

Recommendation. Keep the caregiver training code family as distinct services with their current work and practice expense values, and do not treat these resources as already reflected in evaluation and management valuation. In guidance for any new therapist management codes, separate training a caregiver to carry out a plan from the therapist's additional synthesis, risk assessment, clinically indicated coordination, and management decision. Permit both on the same date only when the work, and any counted time, is separate and the documentation supports each service. Separately, discontinue the full-time billing edit for caregiver training and align these codes with the midpoint convention that applies to other face-to-face timed services, or put any continued full-time requirement through notice and comment.

II.D.4. Potentially Misvalued Services: Evaluation Tiers and Therapist Management

Request one: revalue the OT and PT evaluation tiers

The PT evaluation family is CPT 97161-97163. The OT evaluation family is CPT 97165-97167. Each family distinguishes low, moderate, and high complexity, and CMS assigned 1.20 work RVUs to every tier when the codes took effect for CY 2017. CMS chose that uniform value over the differentiated HCPAC recommendations. That history proves CMS may value therapy independently. It does not prove the three levels consume equal resources. [16]

Equal values weaken the code set's internal signal. When documented complexity and typical time rise and payment does not, the schedule cannot see the additional evaluation work, and practices have little financial capacity to serve more complex beneficiaries. The answer is an empirical review of each family.

CMS should:

• Identify each OT and PT evaluation family under section 1848(c)(2)(K)(ii)(XI) as a possible within-family anomaly.

• Analyze the OT and PT families separately, using chart-confirmed descriptor elements and measured resources.

• Avoid assuming a fixed family total or reducing one tier to finance another. Any downward change should require independently validated, tier-specific evidence, transparent methods, and access analysis. Preserve the low-tier value where the evidence supports it, and raise moderate- and high-tier values to the extent time, intensity, judgment, and practice expense demonstrate.

• Use appropriate reference services after removing work that is not comparable. A shared "complexity" label does not justify importing E/M ratios.

• Model expected tier distribution, coding migration, utilization, budget neutrality, beneficiary cost sharing, and effects on therapy thresholds.

• Publish the data and proposed values for notice and comment, and monitor actual distributions after implementation.

Request two: create encounter-based TM-M and TM-H services

Existing therapy treatment codes remain valid and valuable. Therapeutic exercise and other activity-based codes already include the ongoing assessment, clinical reasoning, skilled adaptation, and treatment decisions needed to furnish the billed intervention safely and effectively. That holds whether the therapist personally furnishes the service or an assistant furnishes it under applicable law and supervision rules. A new management code must not remove, reassign, or devalue that work. [13] [14] [23]

The gap opens on some visits, when the OT or PT performs additional, separately identifiable management beyond the assessment, clinical reasoning, adaptation, and treatment decisions already paid for in an evaluation, reevaluation, treatment, training, or other billed service. The beneficiary need not be globally medically complex. Complexity can come from the condition or functional presentation itself: an evolving musculoskeletal presentation, an unexpected recovery trajectory, changing neurologic or vestibular findings, interacting pain and movement impairments, conflicting postoperative restrictions, or a new gait or balance problem.

What makes it a separate service is the work that changes the plan. The therapist pulls the new information together, decides what to do about it, judges the risk of getting it wrong, reaches the people who have to act, and tells the beneficiary what happens next.

What this looks like in practice

Therapists are attempting this work now, and the payment structure is closing their practices. The clinician below recently appeared on our podcast has given permission to share their experience, and we encourage CMS to contact them directly. [37]

The arithmetic breaks at the first visit. An evaluation for a beneficiary with dementia commonly runs an hour or more and pays the same as a low-complexity evaluation. Subsequent visits bill in 15-minute activity units with practice expense reduced on units after the first under the MPPR. These beneficiaries make poor candidates for remote therapeutic monitoring. Home visits, often the only setting where the relevant problems are visible at all, carry travel time nobody pays for. [4] [6]

Rachel Wiley, OTR/L (Day by Day Home Therapy, Vermont). A master trainer for the Skills2Care dementia care certification, she built a home-based practice around environmental adaptation, caregiver training, and safety. She closed her Medicare-focused practice. Flat-rate evaluation codes and 15-minute activity billing could not sustain time-intensive in-home dementia management. Rachel hosts the dementia collaborative bi-monthly, where therapists meet to discuss best practices and the difficulty of sustaining a practice.

The clinical models are not experimental and the workforce is not missing—what is missing is a way to report the work.

The proposed services

We ask CMS to develop two Medicare-specific, encounter-based G-codes. The labels below are proposal identifiers, not assigned HCPCS codes, and we do not propose RVUs before CMS collects resource data.

TM-M, moderate-complexity therapist management. A separately identifiable service personally performed by an occupational therapist or physical therapist for an established beneficiary under a therapy plan of care; involving a condition or change affecting movement, pain, functional performance, daily activity, participation, or safety; includes synthesis of material interval findings and response-to-treatment information, together with relevant independent information when available and clinically pertinent; a moderate-complexity decision to progress, materially modify, hold, refer, or escalate management; coordination, referral, escalation, or contingency planning when clinically indicated; and communication of an actionable plan to the beneficiary or representative and other involved individuals as appropriate; per qualifying encounter.

TM-H, high-complexity therapist management. A separately identifiable service personally performed by an occupational therapist or physical therapist for an established beneficiary under a therapy plan of care; involving an unstable, progressive, uncertain, or discordant condition or functional presentation; includes synthesis and reconciliation of multiple, conflicting, or consequential findings, restrictions, responses, or inputs; a high-complexity management decision addressing substantial risk to function, participation, safe mobility or activity, recovery, or the ability to remain in the current setting; coordination, referral, escalation, or contingency planning as clinically indicated; and communication of an actionable management or contingency plan; per qualifying encounter.

Proposed selection framework

Every qualifying encounter should require an additional, separately identifiable therapist management decision and an actionable plan. CMS should test how the four dimensions below separate moderate from high complexity instead of importing the office and outpatient E/M counting rules. Diagnosis count, age, comorbidity count, or documentation volume alone should not determine eligibility or tier. Complexity can come from the therapy condition, the movement or functional presentation, the recovery trajectory, or the management risk, even when the beneficiary is not otherwise medically complex.

The services should be non-time-based and reportable no more than once per date by the same discipline. TM-M and TM-H could be furnished with or without a treatment service, and never together. Reporting again would require a new qualifying management need and newly delivered work. CMS should designate the services as "always therapy" codes, require GO or GP reporting, and prohibit same-day reporting with the same discipline's initial evaluation or reevaluation.

The following work would not independently qualify:

• Continuous assessment, response monitoring, symptom review, safety checks, exercise or activity progression, skilled adaptation, ordinary plan modification, patient instruction, home-program review, discharge planning, and documentation already required to furnish an existing treatment code.

• A diagnosis, risk factor, caregiver concern, referral, or additional documentation without the qualifying management work and resulting action.

• Time or work already reported as evaluation, reevaluation, treatment, cognitive intervention, self-care training, caregiver training, HBAI, health coaching, or another management service.

• Routine follow-up on an unchanged plan, or management of a stable issue that does not meet the selected tier.

Qualifying scenarios would include:

• Persistent musculoskeletal pain or an unexpected recovery trajectory, where the PT integrates changed neurologic or movement findings, standardized outcomes, response to loading, and relevant outside guidance, decides whether to progress, materially modify, hold, refer, or escalate, and coordinates an actionable plan.

• Postoperative outpatient rehabilitation where new or discordant findings conflict with surgical instructions, weight-bearing limits, return-to-activity demands, or expected milestones, and the PT has to reconcile restrictions with the surgeon or other treating clinician and implement a revised plan.

• A gait, balance, falls, or vestibular presentation where an abrupt change in falls, freezing, dizziness, exertional tolerance, or assistive-device performance requires the PT to synthesize testing and reports, determine whether therapy can safely proceed, and coordinate referral or escalation.

• A progressive neurologic condition where motor fluctuations, fatigue, medication timing, caregiver capacity, and environmental demands interact to make the current mobility plan unsafe, and the PT has to coordinate a new management or contingency plan.

• An OT encounter involving incompatible transfer or self-care recommendations, abrupt loss of caregiver capacity, or interacting cognitive, environmental, and medical restrictions that cannot be safely implemented together.

In every example, TM-M or TM-H would capture only the additional synthesis, management decision, risk work, coordination, and plan communication. Examination, testing, exercise, activity, neuromuscular reeducation, self-care training, caregiver training, and the continuous assessment and adaptation needed to furnish them stay reportable and valued under the existing codes. [23]

Assistant and overlap protections

Nothing in this proposal should narrow the authorized roles of OTAs or PTAs, reduce payment for existing assistant-furnished therapy services, or characterize assistant care as mechanical. Assistants furnish skilled treatment and contribute clinically meaningful observations, adaptations, education, and communication within applicable state law, supervision requirements, and the therapy plan of care.

For TM-M or TM-H, CMS should require the enrolled occupational therapist or physical therapist to personally perform and document the elements that establish eligibility and tier, meaning the qualifying synthesis, risk assessment, and management decision, and to take responsibility for the resulting plan. Clinically meaningful observations, measurements, education, communication, and implementation furnished by an OTA or PTA within applicable scope and supervision requirements may contribute to the encounter. Those contributions would not substitute for, or be separately counted as, the therapist-level work that establishes the TM service. Separately identifiable assistant-furnished treatment would remain reportable under existing rules. CMS should explain how section 1834(v), the CO and CQ modifiers, and payment rules apply, so the new services neither evade nor expand the statutory differential. CMS should not reduce the existing work and values of therapeutic exercise and other treatment codes on the theory that TM-M or TM-H removes assessment or clinical reasoning from those services. [13] [14] [23]

CMS should also publish edits and examples for overlap with evaluation, reevaluation, caregiver training, HBAI, health coaching, and other care-management payments. The record should identify the management issue, the additional nonduplicative work, the decision, any coordination, referral, escalation, or contingency planning, and the resulting action. Gathering information or writing a longer note should not create a service. A qualifying formal reevaluation should still be reported as a reevaluation and not relabeled. [23]

Valuation and budget process

For TM-M and TM-H, CMS should measure only the additional therapist work: synthesis, risk and intensity, coordination, plan communication, and documentation not already included elsewhere. CMS may compare component work with reevaluation, E/M, or other management services after adjusting for different responsibilities and bundled resources. CMS should not sum full code values or use a professional degree as a valuation proxy.

CMS should estimate utilization by tier, substitution, same-day treatment, site of service, coding shifts, work, practice expense, malpractice expense, geographic adjustments, beneficiary cost sharing, therapy-threshold effects, and the conversion-factor response. If the estimated aggregate change in PFS expenditures exceeds $20 million, section 1848(c)(2)(B)(ii)(II) requires budget-neutral adjustments, which ordinarily run through the conversion factor. New G-codes create no exception. [7]

Corrections to overvalued services elsewhere in the schedule can reduce the residual budget-neutrality adjustment, and each correction needs independent support. CMS is already examining possible overlap in global surgical services and same-day E/M and procedure payment. It may also examine duplicative practice-expense inputs and update supply or equipment prices where the evidence supports it. Avoided hospital, skilled-nursing, or other Part A spending can support the value case for therapy and the design of a model, and it does not transfer automatically into the Part B PFS. [1] [7]

Recommendation. Add 97161-97163 and 97165-97167 to a CMS-led family review. Commission the resource study described above. Develop TM-M and TM-H under section 1848(c)(5) and 42 CFR 414.40. Publish proposed descriptors, values, edits, utilization assumptions, assistant rules, and budget-neutrality effects in the next feasible PFS proposed rule.

II.E. Request for Information: Redesigning Primary Care

What CMS asked. CMS seeks comment on primary-care valuation, technology-enabled care, longitudinal relationships, and prospective primary-care payment in MSSP and Original Medicare. [1]

Comment. Functional status is a core primary-care outcome, and occupational and physical therapists can sometimes be the best first clinician to assess and manage the presenting problem.

PTs are especially well positioned to manage musculoskeletal pain, movement impairments, new gait or balance problems, falls, mobility decline, vestibular complaints, and activity limitations. They screen systems and movement, determine whether the presentation suits physical therapist management or needs medical referral, start evidence-based management, and coordinate escalation when the case calls for it. OTs can play a comparable first-contact role for new loss of ADL or IADL performance, upper-extremity and hand-function problems, cognitive change affecting health routines, and environmental or caregiver barriers. These examples illustrate the point without exhausting it.

Adding OT and PT extends the reach of primary care. It routes a beneficiary quickly to the clinician with the deepest relevant examination and management expertise, and it frees physicians and other qualified practitioners to spend their time where medical diagnosis and management are actually required. These pathways would remain subject to state scope and to applicable Medicare benefit, plan-of-care, and certification requirements. [24] [30]

Recommendation.

• Include functional status, musculoskeletal pain, movement impairment, safe daily activity, gait, balance, mobility, self-management, and caregiver sustainability among the primary-care outcomes CMS tests.

• Test first-contact, direct-referral, and co-management pathways that let primary-care practices and ACOs route a beneficiary to an OT or PT when the therapist is the most appropriate first clinician for the presenting functional, movement, or activity problem, consistent with state direct-access law and applicable Medicare benefit, plan-of-care, and certification requirements, with timely referral to a physician or other qualified practitioner when medical evaluation is indicated.

• Permit and encourage primary-care practices and ACOs to contract with OT and PT practices and to share, consistent with beneficiary preferences and applicable privacy law, the clinical and performance data needed to coordinate care. Triggers would include musculoskeletal pain, new movement impairment, falls, gait or balance change, vestibular symptoms, new ADL or IADL loss, post-acute transition, cognitive change affecting routines, progressive neurologic disease, and caregiver breakdown.

• Keep separately payable therapy outside a primary-care bundle unless CMS identifies the included services, prices the bundle with therapy input, prevents duplicate payment, preserves beneficiary choice, and protects access to skilled maintenance care.

II.H. Current Procedural Terminology Request for Information

What CMS asked. CMS requests information on the relationship between the development of Current Procedural Terminology (CPT) codes and valuation under the Medicare Physician Fee Schedule, including the effects of private ownership and licensing, transparency and stakeholder access, the relationship between coding and medical necessity, and whether alternative approaches could produce more objective, timely, and accessible processes. [1]

Comment. Start with the composition of the valuation committee. Of its 32 voting members, national medical specialty societies appoint 22, while the entire Health Care Professionals Advisory Committee holds a single seat. Neither occupational therapy nor physical therapy has a dedicated seat. [36]

We support CMS's continued examination of these issues. A uniform national coding system serves real administrative and clinical purposes, and we do not recommend that CMS abandon CPT without carefully evaluating the consequences and the available alternatives. However, the current system does raise legitimate concerns that warrant the broader review CMS has opened.

CPT is privately owned and licensed even though it performs an essential function in a federal health care program and is written into the HIPAA administrative simplification framework. Restrictions on access to complete coding information, and the cost of licensing it, burden clinicians, educators, small organizations, technology developers, and others who are trying to understand or improve Medicare payment and compliance. Those restrictions also affect transparency and the ability of stakeholders to take part in coding-policy development.

We experience this burden directly as a small, independent continuing-education provider serving occupational and physical therapy professionals. Public CMS and Medicare Administrative Contractor resources may provide only abbreviated descriptors, such as “CGVR TRNG 1ST 30 MIN,” that are insufficient for the purpose of teaching clinicians how a service should be understood and billed, while fuller code language is subject to AMA licensing restrictions. We sought guidance from the AMA about an educational licensing pathway and received no response. Staff therefore spend substantial time reconstructing basic operational definitions from Federal Register rules, transmittals, and secondary sources, while remaining uncertain about what code language may be quoted or distributed in training. [39]

The Caregiver Training Services code family illustrates the implementation risk on top of the administrative burden: when independent educators cannot clearly reproduce and explain the operative code language, clinicians may hesitate to adopt services CMS has authorized, slowing dissemination to the patients and caregivers the codes were intended to help. [40]

The relationship among CPT code development, the RUC and HCPAC process, and Medicare valuation deserves the same examination. These are distinct functions. Creating a code does not by itself determine whether a service is medically necessary, covered by Medicare, or appropriately valued. RUC recommendations come out of a private, specialty-society process in which participating organizations may have a financial interest in the resulting valuations.

CMS's discussion of longstanding concerns raised by MedPAC, the National Academies, and other observers shows why the agency should ask whether that process consistently produces objective, auditable, and representative evidence. The question presses hardest for services furnished by nonphysician professionals, whose work the current representation, voting, data-access, and evidentiary structures do not adequately capture. [1] [36]

We are not recommending a particular replacement structure. Instead, we ask CMS to keep evaluating whether and how the coding and valuation system could be modernized, and to weigh:

• public access to complete and usable coding information, including workable educational-access pathways for small organizations;

• transparency about the evidence and assumptions used to develop and value codes;

• meaningful representation of the full range of professionals whose services Medicare pays under the PFS;

• timely recognition of changes in clinical practice and emerging models of care;

• the use of objective, auditable data wherever practicable; and

• a clear separation among code creation, Medicare coverage and medical-necessity determinations, and valuation.

This broader inquiry should not delay CMS action on the specific recommendations in this letter. Neither the CPT Editorial Panel nor the RUC or HCPAC holds statutory approval or veto authority over Medicare coverage or payment policy. Section 1848 of the Social Security Act directs the Secretary to establish and review relative values and authorizes CMS to identify and correct potentially misvalued services. CMS's regulations likewise let the agency establish and revise RVUs and related payment policies through rulemaking. [7], [9]-[11] The HIPAA code-set regulations recognize both CPT and HCPCS, and they do not require RUC or HCPAC review before CMS may value a service or establish a Medicare-specific HCPCS Level II code. [12], [25]

CMS may therefore consider the therapy-code recommendations in this letter on its own, including better tiering and valuation of therapy evaluation services and Medicare-specific therapist-management codes, using notice-and-comment rulemaking and appropriate evidence. CMS should not condition consideration of those recommendations on prior action or approval by the CPT Editorial Panel, the RUC, or HCPAC.

Recommendation. CMS should:

• continue its public evaluation of the current coding and valuation framework without prejudging whether CPT should be retained, substantially reformed, supplemented, or replaced;

• evaluate potential reforms against transparency, accessibility, representation, timeliness, innovation, and the quality and objectivity of the supporting evidence; and

• act on the therapy-code recommendations in this letter under its existing statutory and regulatory authority, without treating CPT, RUC, or HCPAC action as a prerequisite.

III.G. Medicare Shared Savings Program

III.G.2.b. Definition of Primary Care Services Used in Assignment

What CMS proposed. CMS proposes to add screening, brief intervention, and referral to treatment; vaccine adverse-effects management; and advance care planning to the primary-care-service definition used in MSSP assignment beginning January 1, 2027. [26]

Comment. We support adding screening, brief intervention, and referral to treatment; vaccine adverse-effects management; and advance care planning to the assignment definition, and CMS should finalize those three additions. We also want CMS to understand why we are not asking it to add therapy evaluation codes in the same way. It is because CMS cannot simply add them under current law. The barrier is a statutory practitioner classification.

Section 1899(c)(1) assigns beneficiaries based on primary care services furnished by an "ACO professional." Section 1899(h)(1) defines that term as an ACO-participating physician or a practitioner described in section 1842(b)(18)(C)(i). That incorporated list covers physician assistants, nurse practitioners, clinical nurse specialists, certified registered nurse anesthetists, certified nurse-midwives, clinical social workers, clinical psychologists, and registered dietitians or nutrition professionals. It does not cover occupational therapists or physical therapists. The regulations carry the same limitation into the MSSP definitions and assignment methodology. Because section 1842(b)(18)(A) and (B) also impose mandatory-assignment and beneficiary-billing rules on the practitioners listed in subparagraph (C), amending that list is not a consequence-free route to MSSP recognition. [27] [28]

Recommendation.

• CMS and HHS should support a targeted congressional amendment to section 1899(h)(1) that expressly recognizes Medicare-enrolled qualified occupational therapists and physical therapists as ACO professionals. A targeted amendment removes the current MSSP exclusion without pulling in unrelated mandatory-assignment and beneficiary-billing consequences from section 1842(b)(18). Broader statutory recognition of OTs and PTs as Medicare practitioners remains an important policy objective, and it should be developed separately, with conforming provisions covering the therapy benefit, enrollment and reassignment, plan-of-care and certification requirements, assignment, beneficiary billing protections, and assistant policy.

• Once Congress acts, CMS should amend 42 CFR 425.20 to recognize OTs and PTs as ACO professionals. CMS should evaluate using initial OT and PT evaluations in beneficiary assignment only through separately noticed modeling that protects beneficiary choice and does not treat routine therapy treatment units as evidence of a primary-care relationship. That modeling should address competing clinicians, episode frequency, low-volume areas, and unintended shifts.

• In the CY 2027 final rule, CMS should name this statutory barrier plainly, so that interested parties take the ACO-professional eligibility request to Congress and any later service-list request to CMS, in that order.

III.G.10. Specialty-Care Engagement and Current Administrative Steps

CMS does not have to wait for legislation to make therapy participation meaningful. Under current authority, CMS should:

• Make OT and PT contributions to episodes easily traceable in ACO data, and give participating practices access to usable beneficiary and performance information.

• Publish examples of lawful ACO participant, ACO provider and supplier, and contracted care-coordination arrangements involving independent OT and PT practices.

• Include functional outcomes and therapy-related utilization in specialty-engagement tools and benchmarking analyses.

• Distinguish an ACO participant, an ACO provider or supplier, a contracted therapy practice, and an "ACO professional" under section 1899(h)(1), and publish the roles currently open to independent OT and PT practices, without implying that an administrative participation arrangement cures the statutory practitioner exclusion.

Recommendation. Pair an explicit legislative recommendation to add OTs and PTs to the statutory ACO-professional definition with immediate administrative steps on contracting, traceability, data access, and functional measures. Once Congress acts, propose conforming ACO-professional regulations and evaluate any assignment changes through separate notice and comment.

IV. Rehabilitative Support MVP and Functional Outcomes

What CMS proposed. For the CY 2027 performance period, CMS proposes to rename and revise the Rehabilitative Support MVP, add functional-improvement measures, and change its included improvement activities. CMS also proposes to sunset traditional MIPS after the CY 2028 performance period and 2030 payment year, making MIPS Value Pathways the reporting framework beginning with the CY 2029 performance period, and to establish a core measure designation requiring clinicians other than small practices to report an applicable core measure. [1]

Comment. We support meaningful functional measurement. Accurate valuation and payment for therapy should not depend on new or untested outcome-reporting requirements. CMS should close measure gaps for occupational therapy, avoid instruments that merely restate treatment volume, and make sure small practices can report without buying costly infrastructure. Before removing caregiver-engagement and cross-setting care-coordination activities from this MVP, CMS should confirm that the remaining or replacement activities fully recognize those functions, and should otherwise retain them. The measure inventory available to rehabilitation clinicians is thin, which makes the core measure designation consequential. A requirement to report a designated core measure should not force reporting of a measure that does not reasonably apply to a participant's practice, and the number of core measures within an MVP should follow the availability of meaningful, broadly applicable measures instead of a fixed share of the inventory.

Recommendation. Use voluntary, CMS-funded testing to determine whether a condition-agnostic patient-reported outcome instrument, such as PROMIS Global Health, adds value alongside discipline-specific functional measures. Collect information at meaningful clinical intervals instead of every visit. Include post-treatment follow-up only where it is feasible. Test risk adjustment, missing data, attribution, and burden, and publish results before any mandatory use. New-code payment, coverage, or eligibility should not depend on untested measure reporting. [29] Confirm in the final rule how CMS will close occupational therapy measure gaps before MVP reporting becomes the only pathway, and adopt an attestation-based exception for participants to whom no designated core measure reasonably applies.

VII. Regulatory Impact and Budget Neutrality

Table D-B5 estimates a 3 percent specialty impact for occupational therapy and physical therapy, which nets to roughly 1.3 percent once the conversion factor is applied, as described under II.B. This modest, methodology-driven result does not revalue therapy services and should not substitute for the service-specific work this letter requests. [1] [2] [31]

For future therapy changes, CMS should publish:

• Baseline utilization and expected utilization by therapy-evaluation tier and proposed therapist-management tier.

• Work, practice-expense, malpractice, geographic, site-of-service, modifier, and threshold effects.

• Beneficiary cost sharing, and impacts on small, rural, and independent practices.

• The gross expenditure change, the section 1848 budget-neutrality adjustment, and any residual conversion-factor redistribution.

• Sensitivity analyses for coding migration, same-day treatment, duplicate services, and induced utilization.

Recommendation. For the therapy workstream, publish the proposed descriptors, values, utilization assumptions, gross expenditure effect, and resulting section 1848 budget-neutrality adjustment, so commenters can assess access, incentives, and redistribution before implementation.

Closing

We ask CMS to open a transparent, CMS-led process to validate and differentiate the OT and PT evaluation tiers, and to develop encounter-based TM-M and TM-H services for additional, separately identifiable therapist management. Neither a RUC recommendation nor RUC or HCPAC participation should be a condition of that workstream. Neither statute nor regulation makes RUC involvement a prerequisite to CMS action.

This proposal preserves existing treatment codes and assistant-furnished care. TM-M and TM-H would apply only where the therapist personally performs the additional management work described under II.D.4, and neither code reduces the authorized role or the payment of an OTA or PTA.

We also ask CMS to put OT and PT HBAI eligibility on a defined near-term rulemaking path, to make sure health and well-being coaching standards recognize OT and PT professional education and licensure without duplicative private credentials, and to support the targeted statutory amendment needed to recognize both professions as ACO professionals. These actions would make payment more accurate while protecting beneficiary choice, skilled maintenance therapy, team-based care, and program integrity.

PTs and OTs are already licensed, already prepared, and in several cases have already closed the practices they built. What they need is a way to report the work.

We appreciate the opportunity to comment and would welcome the chance to provide practitioner input and data.

Sincerely,

Sarah Lyon, OTR/L
Founder and Owner, OT Potential

References

[1] Centers for Medicare & Medicaid Services. Medicare and Medicaid Programs; CY 2027 Payment Policies Under the Physician Fee Schedule and Other Changes to Part B Payment and Coverage Policies; Medicare Shared Savings Program Requirements; and Medicare Prescription Drug Inflation Rebate Program. Proposed rule, CMS-1848-P, 91 FR 43842 (July 16, 2026), Docket No. CMS-2026-2377. https://www.federalregister.gov/documents/2026/07/16/2026-14327

[2] Centers for Medicare & Medicaid Services. Calendar Year (CY) 2027 Medicare Physician Fee Schedule Proposed Rule, fact sheet (July 14, 2026). https://www.cms.gov/newsroom/fact-sheets/calendar-year-cy-2027-medicare-physician-fee-schedule-proposed-rule

[3] Centers for Medicare & Medicaid Services. CY 2026 Physician Fee Schedule final rule, 90 FR 49266 (Nov. 5, 2025), including the final treatment of the 2024 AMA Physician Practice Information Survey. https://www.federalregister.gov/documents/2025/11/05/2025-19787

[4] Social Security Act § 1834(k)(7), 42 U.S.C. § 1395m(k)(7), statutory 50 percent therapy MPPR; and Centers for Medicare & Medicaid Services, CY 2025 PFS proposed and final rules, discussion of 19 physical medicine and rehabilitation codes and duplicative clinical-labor reductions, 89 FR 61596, 61989–61991 (July 31, 2024) and 89 FR 97710 (Dec. 9, 2024). https://www.ssa.gov/OP_Home/ssact/title18/1834.htm; https://www.federalregister.gov/documents/2024/07/31/2024-14828; https://www.federalregister.gov/documents/2024/12/09/2024-25382

[5] American Physical Therapy Association. Medicare Physician Fee Schedule Advocacy, including MPPR policy position (accessed Sept. 6, 2026). https://www.apta.org/advocacy/issues/medicare-physician-fee-schedule; American Occupational Therapy Association. Medicare Part B Calendar Year 2025 Proposed Rule Summary, Code Valuation Updates (July 12, 2024). https://www.aota.org/advocacy/advocacy-news/2024/medicare-b-calendar-year-2025-proposed-rule-summary

[6] Centers for Medicare & Medicaid Services. Therapy Services: CY 2026 Therapy Services Updates, including MPPR rate-file policy and assistant modifier guidance (updated Mar. 10, 2026). https://www.cms.gov/medicare/coding-billing/therapy-services

[7] Social Security Act § 1848, 42 U.S.C. § 1395w-4, especially §§ 1848(c)(2)(B), (c)(2)(K)–(N), and (c)(5). https://www.ssa.gov/OP_Home/ssact/title18/1848.htm

[8] Protecting Access to Medicare Act of 2014, Pub. L. 113-93, § 220, 128 Stat. 1040, 1058–61. https://www.govinfo.gov/content/pkg/PLAW-113publ93/pdf/PLAW-113publ93.pdf

[9] 42 C.F.R. § 414.22, Relative value units (RVUs). https://www.ecfr.gov/current/title-42/section-414.22

[10] 42 C.F.R. § 414.24, Review, revision, and addition of relative value units (RVUs) for physicians’ services. https://www.ecfr.gov/current/title-42/section-414.24

[11] 42 C.F.R. § 414.40, Coding and ancillary policies. https://www.ecfr.gov/current/title-42/section-414.40

[12] 45 C.F.R. §§ 162.1000–162.1011, HIPAA Administrative Simplification code-set standards, including § 162.1002. https://www.ecfr.gov/current/title-45/subtitle-A/subchapter-C/part-162/subpart-J

[13] Social Security Act § 1834(k), (v), 42 U.S.C. § 1395m(k), (v), outpatient therapy payment and the assistant payment differential. https://www.ssa.gov/OP_Home/ssact/title18/1834.htm

[14] 42 C.F.R. §§ 410.59–410.60, outpatient occupational therapy and physical therapy services. https://www.ecfr.gov/current/title-42/section-410.59 and https://www.ecfr.gov/current/title-42/section-410.60

[15] Social Security Act § 1861(g), (p), 42 U.S.C. § 1395x(g), (p), definitions of outpatient occupational and physical therapy services. https://www.ssa.gov/OP_Home/ssact/title18/1861.htm

[16] Centers for Medicare & Medicaid Services. CY 2017 Physician Fee Schedule final rule, therapy evaluation and reevaluation valuation, 81 FR 80170, 80331–80336 (Nov. 15, 2016). https://www.federalregister.gov/documents/2016/11/15/2016-26668

[17] Centers for Medicare & Medicaid Services. CY 2019 Physician Fee Schedule final rule, Medicare-specific virtual communication HCPCS codes G2010 and G2012 and valuation crosswalks, 83 FR 59452, 59483–59487 (Nov. 23, 2018). https://www.federalregister.gov/documents/2018/11/23/2018-24170

[18] Centers for Medicare & Medicaid Services. CY 2024 Physician Fee Schedule final rule, including HBAI practitioner eligibility, timed behavioral health adjustments, and Community Health Integration services, 88 FR 78818, 78976–79010 (Nov. 16, 2023). https://www.federalregister.gov/documents/2023/11/16/2023-24184

[19] Centers for Medicare & Medicaid Services. CY 2025 Physician Fee Schedule final rule, Advanced Primary Care Management services G0556–G0558, 89 FR 97710 (Dec. 9, 2024); CMS, Advanced Primary Care Management Services (updated Jan. 26, 2026). https://www.federalregister.gov/documents/2024/12/09/2024-25382 and https://www.cms.gov/medicare/payment/fee-schedules/physician-fee-schedule/advanced-primary-care-management-services

[20] American Occupational Therapy Association. Occupational Therapy Practice Framework: Domain and Process—Fourth Edition. American Journal of Occupational Therapy. 2020;74(Suppl. 2):7412410010. https://doi.org/10.5014/ajot.2020.74S2001; see also AOTA, Occupations and Everyday Activities. https://www.aota.org/practice/domain-and-process/occupations-everyday-activities

[21] Pyatak EA, Carandang K, Vigen CLP, et al. Occupational Therapy Intervention Improves Glycemic Control and Quality of Life Among Young Adults With Diabetes: The REAL Diabetes Randomized Controlled Trial. Diabetes Care. 2018;41(4):696–704. https://doi.org/10.2337/dc17-1634

[22] American Physical Therapy Association. Physical Therapists’ Role in Prevention, Wellness, Fitness, Health Promotion, and Management of Disease and Disability; Role of the Physical Therapist and APTA in Behavioral and Mental Health. https://www.apta.org/apta-and-you/leadership-and-governance/policies/pt-role-advocacy; https://www.apta.org/apta-and-you/leadership-and-governance/policies/role-pt-apta-behavioral-mental-health. See also Coronado RA, Brintz CE, McKernan LC, et al. Psychologically informed physical therapy for musculoskeletal pain. Pain Reports. 2020;5(5):e847. https://pmc.ncbi.nlm.nih.gov/articles/PMC7808677/

[23] Centers for Medicare & Medicaid Services. Medicare Benefit Policy Manual, Pub. 100-02, ch. 15, §§ 220–230; Medicare Claims Processing Manual, Pub. 100-04, ch. 5, therapy evaluation and reevaluation requirements. https://www.cms.gov/regulations-and-guidance/guidance/manuals/downloads/bp102c15.pdf and https://www.cms.gov/regulations-and-guidance/guidance/manuals/downloads/clm104c05.pdf

[24] American Physical Therapy Association. Practice Advisory on Primary Care Physical Therapy (Oct. 8, 2025). https://www.apta.org/article/2025/10/08/now-available-apta-practice-advisory-on-primary-care-physical-therapy. See also Cattrysse E, et al. Impact of direct access on the quality of primary care musculoskeletal physiotherapy: a scoping review. Archives of Physiotherapy. 2024;14:15. https://pmc.ncbi.nlm.nih.gov/articles/PMC11220609/

[25] Centers for Medicare & Medicaid Services. Healthcare Common Procedure Coding System (HCPCS) Level II Coding Procedures and Current and Prior Years’ Coding Decisions. https://www.cms.gov/medicare/coding-billing/healthcare-common-procedure-system/current-prior-years-level-ii-coding-decisions

[26] Centers for Medicare & Medicaid Services. CY 2027 PFS Proposed Rule: Medicare Shared Savings Program Proposals, fact sheet (July 2026). https://www.cms.gov/newsroom/fact-sheets/calendar-year-cy-2027-medicare-physician-fee-schedule-proposed-rule-cms-1848-p-medicare-shared

[27] Social Security Act §§ 1899(c)(1), (h)(1), 42 U.S.C. § 1395jjj(c)(1), (h)(1), and § 1842(b)(18)(C)(i), 42 U.S.C. § 1395u(b)(18)(C)(i). https://www.ssa.gov/OP_Home/ssact/title18/1899.htm; https://www.ssa.gov/OP_Home/ssact/title18/1842.htm

[28] 42 C.F.R. §§ 425.20, 425.400, and 425.402, MSSP definitions and beneficiary assignment methodology. https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-B/part-425

[29] HealthMeasures. Patient-Reported Outcomes Measurement Information System (PROMIS®), including PROMIS Global Health. https://www.healthmeasures.net/explore-measurement-systems/promis

[30] American Occupational Therapy Association. Occupational Therapy Practice in Primary Care Settings. https://www.aota.org/practice/practice-settings/primary-care

[31] Social Security Act § 1833(z)(3)(B), 42 U.S.C. § 1395l(z)(3)(B), defining “eligible professional” for QP determinations by reference to section 1848(k)(3)(B); see reference [7], including section 1848(k)(3)(B)(iii), which includes physical and occupational therapists. https://www.ssa.gov/OP_Home/ssact/title18/1833.htm

[32] Medicare Payment Advisory Commission. June 2025 Report to the Congress: Medicare and the Health Care Delivery System, ch. 1, recommending that Congress replace the current-law updates to the physician fee schedule with an annual update based on a portion of the growth in the Medicare Economic Index. https://www.medpac.gov/document/june-2025-report-to-the-congress-medicare-and-the-health-care-delivery-system/

[33] Provider Reimbursement Stability Act of 2026, H.R. 8163, 119th Cong. https://www.congress.gov/bill/119th-congress/house-bill/8163

[34] Centers for Medicare & Medicaid Services. Therapy Services, CY 2025 updates, caregiver training services billing edit (Disposition 11) requiring that the full time stated in the code descriptor be furnished, effective for services on or after January 1, 2025 (posted February 14, 2025). https://www.cms.gov/medicare/coding-billing/therapy-services/spotlight-archive

[35] Cuozzo J, Choula R, with Cromer T and Greer A. Exploring Early Adoption of Medicare Caregiver Training Services. AARP Public Policy Institute, April 29, 2026. https://www.aarp.org/pri/topics/ltss/family-caregiving/utilization-and-impact-of-caregiver-training-services/

[36] American Medical Association. Composition of the RVS Update Committee (RUC). https://www.ama-assn.org/about/rvs-update-committee-ruc/composition-rvs-update-committee-ruc

[37] Practitioner accounts. Personal communications to OT Potential, permission to share confirmed: Rachel Wiley, OTR/L (Day by Day Home Therapy, Vermont). Contact information available on request.

[38] Skills2Care, a registered program of Thomas Jefferson University, referenced in Ms. Wiley's account. https://www.jefferson.edu/academics/colleges-schools-institutes/rehabilitation-sciences/departments/occupational-therapy/skills2care.html

[39] Sarah Lyon, OTR/L, founder and owner of OT Potential. Email correspondence to Dana Strauss describing OT Potential's experience seeking CPT educational-licensing guidance and teaching the Caregiver Training Services code family (Sep 1, 2026), including an unanswered AMA licensing inquiry submitted Feb 3, 2026. On file with OT Potential.